Gold nanostars (AuNSs) exhibit modulated plasmon resonance and have a high SERS enhancement factor. However, their low colloidal stability limits their biomedical application as a nanomaterial. Cationic β-cyclodextrin-based polymer (CCD/P) has low cytotoxicity, can load and transport drugs more efficiently than the corresponding monomeric form, and has an appropriate cationic group to stabilize gold nanoparticles. In this work, we functionalized AuNSs with CCD/P to load phenylethylamine (PhEA) and piperine (PIP) and evaluated SERS-based applications of the products. PhEA and PIP were included in the polymer and used to functionalize AuNSs, forming a new AuNS-CCD/P-PhEA-PIP nanosystem. The system was characterized by UV–VIS, IR, and NMR spectroscopy, TGA, SPR, DLS, zeta potential analysis, FE-SEM, and TEM. Additionally, Raman optical activity, SERS analysis and complementary theoretical studies were used for characterization. Minor adjustments increased the colloidal stability of AuNSs. The loading capacity of the CCD/P with PhEA-PIP was 95 ± 7%. The physicochemical parameters of the AuNS-CCD/P-PhEA-PIP system, such as size and Z potential, are suitable for potential biomedical applications Raman and SERS studies were used to monitor PhEA and PIP loading and their preferential orientation upon interaction with the surface of AuNSs. This unique nanomaterial could be used for simultaneous drug loading and SERS-based detection. Gold nanoparticles are employed in bionanotechnology because they exhibit excellent optoelectronic properties and high surface reactivity, which enable preparation of biocompatible nanomaterials with specific functions ,2,3,4. BGold nanostars (AuNSs) are of special interest because morphological modifications, such as number of tips and their length, can be used to tune the position of the band of localized surface plasmon resonance ,20 to plAn increase in the reactive surface area due to specific morphology of AuNSs causes a substantial decrease in colloidal stability ,28,29. Mβ-Cyclodextrin (βCD) is a water-soluble nontoxic cyclic oligosaccharide formed by 7 linked units of glucopyranose with a bucket-like shape; this compound has various biomedical applications and is approved by the FDA. The βCD cavity is partially hydrophobic and can thus incorporate nonpolar species of appropriate dimensions to form an inclusion complex with increased solubility and protection against oxidation, enzyme-mediated degradation or photolysis ,49. Due In this work, we synthesized AuNSs using a simple and surfactant-free method. The prepared nanoparticles produce an absorbance band located within a biological window. Subsequently, AuNSs were functionalized with a cationic cyclodextrin-based polymer (CCD/P) to increase their stability over time, forming a new nanomaterial, AuNS-CCD/P. Phenylethylamine (PhEA) and piperine (PIP) were incorporated in the system to evaluate drug co-loading capacity and provide a proof-of-concept of the potential SERS application of the AuNS-CCD/P system.PhEA is a psychoactive stimulant employed as an antidepressant and does not induce tolerance. However, PhEA is rapidly metabolized in the body by the MAO-B enzyme and thus cannot be accumulated at sufficient concentrations in the brain ,79. PIP This study may contribute to the development of nanotechnology systems based on AuNSs and CCD/P; these materials have not been reported previously. The new AuNS-CCD/P system can be used for simultaneous drug loading and in SERS-based detection.4*3H2O) ≥ 99.9%, molar weight: 393.83 g/mol; βCD (C42H70O35) ≥ 98%, 1134.98 g/mol; (±) epichlorohydrin  ≥ 99%, 92.52 g/mol; choline chloride  ≥ 98%, 139.62 g/mol; PhEA  ≥ 99%, 121.18 g/mol, δ: 0.962 g/mL; PIP -5--1-(piperidin-1-yl)penta-2,4-dien-1-one, C17H19NO3) ≥ 97%, 285.3 g/mol; and sodium hydroxide (NaOH) ≥ 97%, 40.00 g/mol were provided by Sigma Aldrich . Hydroxylamine hydrochloride (NH2OH*HCl) ≥ 98%, 69.49 g/mol; hydrochloric acid (HCl) for analysis, 36.46 g/mol; and water (nanopure) were provided by Merck .Tetrachloroauric acid . The precursors EP, CC, βCD, PhEA, and PIP and the samples of CCD/P and CCD/P-PhEA-PIP were measured directly; the samples of AuNS-CCD/P (10 mg) and AuNS-CCD/P-PhEA-PIP (10 mg) were lyophilized and then measured. FT/IR spectroscopy was performed using a spectrometer . Thermogravimetric analysis (TGA) was performed using an instrument . The temperature of the furnace was programmed to increase at a rate of 10 °C/min from 30 °C to 800 °C under an atmosphere of N2 (a flow rate of 20 mL/min). Mass spectrometry was performed using a MALDI-TOF Microflex  in the positive and negative ion mode by linear detection in the presence of the DHB matrix. Entrapment efficiency and loading capacity were determined using an SPR instrument  with an autosampler system. Data acquisition was performed using Integrated SPR Autolink . The data were processed using TraceDrawer 1.6.1 and OriginPro 8.0 software.UV–VIS spectroscopy was performed at 25 °C using a UV 2450 spectrophotometer  with water as the baseline. Zeta potential and dynamic light scattering analyses were performed at 25 °C using a Zetasizer . The size distribution of the samples was determined based on the results of the intensity distribution values using the cumulant method. The Smoluchowski approximation was used to calculate the Z potentials based on the measured electrophoretic mobility. Field emission scanning electron microscopy (FE-SEM) was performed using a Leo Zeiss Supra 35VP microscope at the acceleration voltages of 15 kV and 2 kV. Transmission electron microscopy (TEM) was performed using a JEOL 2000FX TEM microscope at 200 kV to determine the average particle size and distribution of the samples. The average particle size was calculated using Digital Micrograph software. −1 line of silicon using a lens with a 50× objective. The laser power incident on the sample was approximately 0.2 mW. The acquisition time was set between 10 and 20 s per accumulation; the average number of accumulations was 10, with a spectral resolution of 4 cm−1. Data were collected between 0 and 3000 cm−1, and the recorded spectral region was between 200 and 2000 cm−1. The conditions of spectral recording and laser wavelength were selected to avoid the degradation and possible fluorescence of the samples; accordingly, the 785 nm laser line was used for SERS and Raman spectral scanning. Raman spectra of PhEA were measured in samples prepared by drying of multiple drops of the solution on silica. The Raman spectra of PIP, CCD/P, and CCD/P-PhEA-PIP were collected in the solid state. The SERS spectra of AuNS-CCD/P and AuNS-CCD/P-PhEA-PIP were obtained in aqueous solution supported on silica.The Raman and SERS measurements were performed using a micro-Raman RM 1000 spectrometer  equipped with lasers at 514, 633, and 785 nm. The apparatus was coupled to a DM LM microscope  and an electrically cooled CCD camera . The Raman signal was calibrated to the 520 cmAll calculations were performed using density functional theory (DFT) in Gaussian09, revision D.01 , on a hiThe first step included molecular geometry optimization. Scans over various angles were performed to identify various local minima. The lowest local minima geometry was used for each molecule in the gas phase. Additionally, a harmonic vibrational frequency calculation was performed to verify that the optimized geometries were genuine minima in the potential energy surface. No symmetry or geometry restrictions were imposed during the optimizations. The second step included an anharmonic vibrational frequency and Raman intensity calculations, through second-order vibrational perturbation theory (VPT2) , for preSuccessful production of AuNSs was confirmed using UV–VIS spectroscopy; this technique allows the evaluation of optical properties of nanoparticles by providing preliminary information on the size, shape, or state of aggregation, which are associated with the surface plasmon resonance characteristics of the nanoparticles ,95. FiguMinati et al.  reportedThe tested dilution factors ranged from 2× to 10×, and 3×–10× dilutions resulted in stable AuNSs. The strategy used to resuspend AuNSs is not trivial. Thus, two methods to resuspend previously agglomerated AuNSs were compared: sonication and mechanical agitation. The surface charges of the resuspended colloidal solutions were −49 (±3) mV in the case of sonication and −55 (±2) in the case of mechanical agitation. The hydrodynamic diameters were 121 (±18) nm in the first method and 249 (±49) nm in the second method, and polydispersity indices were 0.22 and 0.34, respectively. The UV–VIS spectra showed an increase in absorbance, a hypsochromic shift and a lower plasmon bandwidth in particles obtained by sonication. Therefore, the mechanical agitation method was not sufficient to disaggregate colloidal solution after agglomeration, while the sonication method achieved efficient resuspension. Moreover, comparison of these characteristics with the properties of AuNSs in the colloidal solution immediately after synthesis indicated that sonication can enrich AuNSs. Thus, sonication was used for functionalization of the surface of AuNSs with CCD/P and for washing.1H-NMR spectroscopy. AuNSs were stabilized and functionalized with CCD/P and the PhEA and PIP drugs to construct a new nanosystem for drug co-loading. Initially, CCD/P was synthesized according to the protocol of Li et al.  via basi−1 corresponded to the stretching of the OH groups, and the changes in the interval from 1050 to 1200 cm−1 corresponded to the stretching of the ether bonds, suggesting the formation of the ether bonds by the epoxide moiety of EP attacking hydroxyl groups of CC and βCD [CCD/P was also characterized by IR spectroscopy and mass spectrometry. In the IR spectrum, the attenuation of the band near 3600 cm and βCD  in agree1H-NMR. The PhEA and PIP drugs were used to evaluate the drug inclusion capacity of the polymers. The resulting loaded CCD/P was used for surface modification of AuNSs. The inclusion process was characterized using −1 [−1 [Integration of the signals corresponding to each drug in the CCD/P-PhEA-PIP system showed a stoichiometric relationship corresponding to three-fold higher inclusion of PIP than that of PhEA. Furthermore, integration of signals corresponding to βCD cavities of CCD/P in the CCD/P-PhEA-PIP system showed a stoichiometric relationship corresponding to 4:1:3 βCD: PhEA:PIP, suggesting strongly that the inclusion of the drugs occurred exclusively through the βCD cavities in a 1:1 ratio  of the polymer. Therefore, high colloidal stability (over 7 days) of the AuNS-CCD/P and AuNS-CCD/P-PhEA-PIP systems was due to the steric impediment provided by the polymer and the drugs loaded into the polymer, which inhibited the aggregation of the nanostructures.1H-NMR and UV–VIS spectra of the AuNS-CCD/P and AuNS-CCD/P-PhEA-PIP systems demonstrated that the presence of AuNSs did not influence the inclusion and stability of CCD/P loaded with PhEA and PIP  may enable future studies aimed at applications in multitherapy, drug delivery, or theranostics. Based on these results, we continued the investigation of the surface using SERS to contribute to the development of applications of the AuNS-CCD/P system based on monitoring of the species proximal to the surface of the particles.Raman spectroscopy was used to study the co-loading of PhEA and PIP in the AuNS-CCD/P nanomaterial and to determine important interactions of these drugs with the gold atoms on the surface of the AuNS-CCD/P-PhEA-PIP system. The Raman spectra of PhEA (A) and PIP (B) were directly compared to the SERS spectrum of AuNS-CCD/P-PhEA-PIP (F). The CCD/P (C) and CCD/P-PhEA-PIP (D) systems showed similar Raman spectra; thus, it was not possible to assign or recognize the signals of both drugs. The registered signals and their assignments are shown in −1 corresponded to amine H wagging, which shifted to 827 cm−1 due to the interaction of the amino groups with the AuNSs surface. The other signals corresponded to the vibrations associated with the aryl rings, which were displaced due to the inclusion in the CCD/P. The vibrations at 1009, 1040, 1164, 1597, and 1617 cm−1 in the PhEA spectra were detected and were parallel to the aryl axis.In the case of PhEA, the signal at 829 cm−1, respectively, corresponding to the most intense signals. This result suggests that PhEA included in CCD/P was oriented perpendicular (┴) to the AuNSs surface probably due to the NH2–Au interactions.In the SERS spectrum, the two signals corresponding to the C=C symmetrical bending and to H rocking with deformation of the aryl ring were shifted to 1008 and 1036 cm−1 were related to the H vibrations of the aryl and diene groups, and these signals were displaced in the SERS spectra due to the inclusion of PIP onto CCD/P.The signals at 1111, 1237, 1302, and 1376 cm−1 in the PIP spectrum corresponded to the combined bands of piperidine, aryl and aliphatic vibrations. The signals at 1590, 1614, and 1637 cm−1 were the major peaks of PIP in the SERS spectra. These vibrations were not in a single plane, and changes in their intensity, disappearance or displacement were attributed to a parallel (‖) orientation to the surface of AuNS due to dynamic inclusion of PIP in CCD/P.The signals at 1122, 1141, 1595, 1610, 1636, and 1645 cm−1, which was displaced to 297 cm−1 in the AuNS-CCD/P-PhEA-PIP spectrum. This signal corresponded to vibrations derived from the interaction between AuNSs and CCD/P.The SERS spectrum of the AuNS-CCD/P system had a signal at 293 cmThe differences in the SERS and Raman spectra, mainly in the relative intensity and wavenumber shifts, were related to different orientations of the analytes on the AuNSs surface according to SERS selection rules ,108. TheHighly anisotropic nanoparticles, such as AuNSs, have high SERS enhancement factors ,110,111.Minor adjustments to the reported method of AuNS synthesis increased colloidal stability of the particles over time. Spontaneous agglomeration and resuspension enabled functionalization and purification of AuNSs. CCD/P was used to functionalize AuNSs and effectively load the PhEA and PIP drugs to generate a new AuNS-CCD/P-PhEA-PIP nanomaterial. Loading of the drugs in the polymer was 95 ± 7%. The highly anisotropic surface of AuNSs enabled the investigation of the composition, interaction and orientation of both drugs in the nanosystem using SERS. Thus, this unique nanomaterial can be used for simultaneous drug loading and in the studies of SERS-based detection, leading to potential applications in therapeutic drug monitoring or theranostics.


Plastic bottles are generally recycled by remolding them into numerous products. In this study, waste from plastic bottles was used to fabricate recycled polyethylene terephthalate (r-PET) nanofibers via the electrospinning technique, and high-performance conductive polyethylene terephthalate nanofibers (r-PET nanofibers) were prepared followed by copper deposition using the electroless deposition (ELD) method. Firstly, the electrospun r-PET nanofibers were chemically modified with silane molecules and polymerized with 2-(methacryloyloxy) ethyl trimethylammonium chloride (METAC) solution. Finally, the copper deposition was achieved on the surface of chemically modified r-PET nanofibers by simple chemical/ion attraction. The water contact angle of r-PET nanofibers, chemically modified r-PET nanofibers, and copper deposited nanofibers were 140°, 80°, and 138°, respectively. The r-PET nanofibers retained their fibrous morphology after copper deposition, and EDX results confirmed the presence of copper on the surface of r-PET nanofibers. XPS was performed to analyze chemical changes before and after copper deposition on r-PET nanofibers. The successful deposition of copper one r-PET nanofibers showed an excellent electrical resistance of 0.1 ohms/cm and good mechanical strength according to ASTM D-638. Flexible electrically conductive materials have gained significant demand for electronics and telecommunication systems because of their capability to convey electrical properties in this century . The incWearable electronics rely heavily on metal-coated textiles to produce textile materials with special functional properties. In the previous research studies, textile based conductive materials were widely fabricated via various deposition methods ,10. CurrThe previous textile based conductive fabrics contain a low surface area and high porous structure, which can limit the metal deposition rate. Electrospun nanofibers have gained much attraction in wide applications due to their high surface area and can create a high metal deposition rate . RecentlNanotechnology has deep roots in every field of life and in helping the research community to solve a wide a range of challenges . ElectroRecycled polyethylene terephthalate (r-PET) was obtained from water bottles at a convenience store in Japan and were utilized directly without further purification. Trifluoracetic acid, chloroform, vinyltrimethoxysilane (98%), (2-(methacryloyloxy) ethyl) tri-methyl-ammonium chloride solution (METAC), ammonium tetra-chloro-palladate (II), and copper (II) sulfate pentahydrate were purchased from Sigma Aldrich USA . Chemical reagents, potassium sodium tartrate tetrahydrate, formaldehyde, potassium persulfate, and sodium hydroxide were purchased from Sinopharm Chemical Reagent Co., Ltd. .2) and dissolved in the TFA/chloroform with a ratio of 1:3 in order to make a 15% w/w polymer composition. Electrospinning was performed using a high-voltage power supply  at room temperature. The prepared solution was poured into a syringe with a capillary tip attached having an internal diameter of 0.6 mm and keeping a 0.5 mL/h flow rate with a supplied voltage of 15 kV. The as-prepared r-PET nanofibers were collected on aluminum foil wrapped over a rotary collector system, and the capillary tip to collector distance was set as 15 cm. After electrospinning, the r-PET nanofibers were peeled off and dried overnight before further use.The r-PET nanofibers were fabricated by following the previous protocol . BrieflyGraphical abstract represents the complete fabrication process to prepare conductive r-PET nanofibers and characterized by 4 steps . Each step is explained below.The obtained r-PET nanofibers were hydrophobic, and to create hydroxyl groups before the silanization process, plasma treatment was needed. Previously, plasma treatment was used to create hydroxyl groups on textile substrates . The r-Pv/v) vinyl-tri-methoxy-silane (VTMS) for 20 min. The VTMS-treated r-PET nanofibers were rinsed with DI water and immediately vacuum dried at 50 °C. The successful VTMS treatment provided the hydrophobic surface of r-PET nanofibers due to the presence of dense vinyl groups.The plasma treated r-PET nanofibers were placed in an ethanol solution having 10% (v/v) METAC aqueous solution (100 mL) and 60 mg of potassium persulfate (KPS) for 60 min to carry out the polymerization of METAC (PMETAC) brushes while stirring at 60 °C. Finally, the polymerized r-PET nanofibers were washed with DI water and vacuum dried at 50 °C for 2 h.The silanized-treated r-PET nanofibers were immersed into a polymerization solution, which contained a mixture of 20% (4)2PdCl4) for 20 min for the ion-exchange reaction. During the ion-exchange, [PdCl4]2- catalytic ions were immobilized onto the quaternary ammonium groups of PMETAC polymer chains, and the samples were gently washed with DI water. Further, an ELD bath was prepared to contain Solutions A and B (The electroless deposition (ELD) of copper was carried out on PMETAC r-PET nanofibers by following previous protocols ,22,23,24 A and B  with a rScanning electron microscopy  with an acceleration voltage of 30 kV was used to observe the surface morphology of the neat r-PET nanofibers and copper-coated r-PET nanofibers. The EDX images and spectrum were obtained using an S-3000 N, Hitachi Ltd. X-ray spectroscopy, Japan. All samples of SEM and EDX were sputter coated with gold before analysis. The X-ray spectroscopy (XPS)  was performed to analyze the chemical composition of the neat r-PET nanofibers and copper-coated r-PET nanofibers.An OCA-40 contact angle instrument (Data physics Filderstadt Germany) was applied to determine the water contact angle of neat r-PET nanofibers and each process involved to fabricate the conductive r-PET nanofibers.σ, and E represents the stress, strain, and Young’s modulus, respectively. l shows the original length of the specimen. F is the applied force on the specimen, and A is the area of the specimen.The mechanical properties of neat r-PET nanofibers and copper-coated r-PET nanofibers after the ELD process were tested by a Titan Universal Tester 3-910, Titan Company Ltd., Hessen, Germany. The tensile strength was measured according to the ASTM D-638 standard. During the test, the speed was set at 5.0 mm/min. The values of the stress-strain curves and Young’s modulus were calculated by using the following Equations (1)–(3), respectively .(1)ε=Δl2 r-PET nanofibers with an average thickness of 120 µm. The shrinkage of r-PET nanofibers after the ELD process was calculated by using Equation (4) for lengthwise shrinkage and Equation (5) for widthwise shrinkage, respectively.The shrinkage test was performed by taking 5 × 5 cmLs is lengthwise shrinkage, L is the original length of the samples, and L∆ is the change in the original length after the ELD process. In Equation (5), Ws is widthwise shrinkage. W is the original width of the samples. w∆ is the change in the original width after the ELD process. In Equation (6), Rs is the residual shrinkage after the ELD process.In Equation (4), In this study, neat r-PET nanofiber samples were assessed by SEM (scanning electron microscopy) and analyzed to identify the surface morphology before and after the copper ELD process. The SEM images are shown in The EDX elemental mapping was applied to verify the presence of copper metal in r-PET nanofibers as shown in To investigate the specific elements and the presence of the chemical bonds, the XPS analysis was performed on neat r-PET nanofibers and copper-coated r-PET nanofibers to ensure the presence of copper elements after the ELD process, which was also confirmed by the EDX process. The water contact angle was used to examine each successful step required for the ELD process. In the electroless deposition, temperature and time had significant effects on the deposition of copper on r-PET nanofibers. After the optimization of the temperature, for the deposition of copper on the r-PET nanofibers, time optimization was also equally important, as shown in According to the experimental results, continuous copper deposition could be obtained as the deposition time was extended up to 30 min, but the optimal time was observed as 15 min for the deposition of copper on the r-PET nanofibers at a temperature of 40 °C. In the optimum condition, the deposition of copper was good, showing the lowest resistance. The mechanical properties of the pristine r-PET nanofibers and copper-coated r-PET nanofibers were investigated. As shown in The r-PET nanofibers after being exposed to the salinization and the ELD process substantially shrunk, so it was necessary to analyze the shrinkage behavior in the r-PET nanofibers after the ELD process; there was exaggeration in documenting the finding. In this research study, copper-coated r-PET nanofibers were successfully fabricated by the process of electroless deposition. The optimized temperature was observed as 40 °C, and the optimized time of 15 min was set for proper copper deposition on the r-PET nanofibers. The SEM images evidently showed the fibrous morphology of the r-PET nanofibers with an average diameter of 350 nm, and the copper-coated r-PET nanofibers retained the fibrous morphology with a slight increase in the average diameter of 700 nm. The optimized copper-coated r-PET nanofibers were composed of 71.6% copper and showed a low electrical resistance of 0.1 Ω. Moreover, the r-PET nanofibers were flexible and showed good mechanical strength. As-prepared, conductive r-PET nanofibers have good potential and could be used in many applications such as wearable electronics, flexible sensors, and energy storage.


Monascus purpureus, with added niacin (27 mg) and policosanols (10 mg) (LEVELIP DUO®), or placebo. The mean LDL-Cholesterol (LDL-C) change at Week 8 was −32.5 ± 30.2 mg/dL (−19.8%) in the combined nutraceutical group and 2.5 ± 19.4 mg/dL (2.3%) in the placebo group. The estimated between-group difference of −39.2 mg/dL  indicates a statistically significant difference between treatments in favor of the combined nutraceutical (p < 0.0001). Total Cholesterol (TC), non-HDL cholesterol (non-HDL-C), Apolipoprotein B, TC/HDL-C and LDL-C/HDL-C improved in a similar way in the combined nutraceutical group only. No significant changes in other clinical and laboratory parameters were observed. In conclusion, the tested combined nutraceutical was well tolerated, while significantly reducing the plasma levels of LDL-C, TC, non-HDL-C, ApoB, TC/HDL-C and LDL-C/HDL-C ratios in mildly hypercholesterolemic patients. Trial registration : NCT03739242.Phytosterols and red yeast rice are largely studied cholesterol-lowering nutraceuticals, respectively inhibiting the bowel absorption and liver synthesis of cholesterol. Our aim was to test the effect of combined nutraceutical-containing phytosterols and red yeast rice vs. a placebo on the lipid profile. We performed a parallel arms, double-blind, placebo-controlled clinical trial, randomizing 88 moderately hypercholesterolemic subjects to treatment with a combined nutraceutical containing phytosterols (800 mg) and red yeast rice, standardized to contain 5 mg of monacolins from  Hypercholesterolemia is a largely prevalent cardiovascular disease risk factor in the general population, and its early reduction seems to be an effective preventive strategy . HoweverIn the last few decades, a relatively large number of nutraceuticals and functional foods has been studied for their ability to decrease cholesterolemia in humans . The mosPlant sterols and stanols (phytosterols) are natural constituents of the plant cell membrane . From a Oryza sativa) as result of a yeast , whose typical red coloration is due to the presence of some specific pigments, by-products of the fermentative metabolism process [Red yeast rice is a nutraceutical obtained by the fermentation of rice  reduced LDL-C on average by 39.4 mg/dL compared to placebo, which was comparable to the reduction achieved with regular-dosed statins  . Based o® on LDL-C blood levels in subjects with sub-optimal blood cholesterol levels over an 8-week period. The secondary objective was the evaluation of effects of the tested combined nutraceuticals on other lipoproteins and on the estimated cardiovascular risk.In this context, the primary objective of the study was to evaluate the effects of LEVELIP DUOThis parallel-armed, double-blind, randomized clinical trial was carried out in 90 moderately hypercholesterolemic subjects, non-smokers, pharmacologically untreated, in primary prevention for cardiovascular diseases, consecutively enrolled in the ambulatory service of cardiovascular disease prevention in the Medical and Surgical Sciences Department of the University of Bologna.The inclusion criteria were age between 30 and 75, and LDL-C level between 115 and 190 mg/dL, confirmed in at least two sequential checks prior to signing the consent form.Personal history of cardiovascular disease or risk equivalents;Triglycerides (TG) ≥400 mg/dL;2);Obesity .The study design has been detailed in At the enrollment visit , patients were given standard behavioral and qualitative (not quantitative) dietary suggestions to correct unhealthy habits. Standard diet advice was given by a dietitian and/or specialist doctor. A dietitian and/or specialist doctor periodically provided instructions on dietary intake recording procedures as part of a behavior modification program, and then later used the subject’s food diaries for counseling. In particular, the subjects were instructed to follow the general structure of a Mediterranean diet, avoid excessive intakes of dairy products and red meat-derived products during the study, and maintain overall constant dietary habits . Individ® or placebo, one tablet after dinner. LEVELIP DUO® is a registered combination of phytosterols (800 mg) and other registered ingredients including red yeast rice standardized to contain 5 mg monacolins from Monascus purpureusi, with niacin (27 mg) and policosanols (10 mg) (Dif1/Stat®) [After 2 weeks of diet and physical activity , if the LDL-C and TG values were confirmed, the patients were randomly allocated to a treatment with LEVELIP DUO1/Stat®) ,22. The 1/Stat®) .The active products and placebo were administered as indistinguishable tablets . The treatment then continued for 8 weeks. Clinical and laboratory data have been obtained at the baseline (T0), after 4 weeks (T1) and at the end of the trial .® or placebo) in a 1:1 ratio. A paper-based randomization procedure assigned a randomization number to the patient, which has been used to link the patient to a treatment arm and specified a unique kit number for the package of treatment to be dispensed to the patient. The randomization numbers were generated using a procedure to ensure that treatment assignment is unbiased.A computer-generated randomization list produced by the trial statistician randomized patients to one of the two treatment groups  .Considering the primary endpoint of the study as the reduction from baseline to week 8 in LDL cholesterol level, and the data available from literature , a reduc® for Windows release 9.4 (64-bit) or later . For each secondary efficacy variable, an ANCOVA model was used to estimate the treatment’s effect on the changes from baseline at week 8, considering the planned treatment group as the factor and the baseline value of the parameter as the continuous covariate. The results are reported as Least Squares Means together with associated two-tailed 95% CI. The difference in Least Squares Means between the nutraceutical combination group and placebo group was estimated with two-tailed 95% CI and p value. If the assumption of the normality of the residuals was violated, the ANCOVA model was fitted to rank transformed data. A p value less than 0.05 was considered significant for all tests.Statistical tables, figures, listings and analyses were produced using SASEnrolled patients were age- and sex-matched. We enrolled 38 men  and 47 women . The baseline characteristics of patients assigned to the different treatments (active and placebo) were similar, and no significant differences were observed regarding the studied parameters . PatientOveral, 85 subjects (94.4%), 43 in the active treatment group and 42 in the placebo group, were compliant (compliance levels between 80% and 120%). One patient (2.33%) in the active treatment group had compliance lower than 80%, whereas 1 patient (2.33%) in the placebo group had compliance greater than 120%.Dietary habits remained overall unchanged during the study.The primary variable of the study was the change from baseline at week 8 in LDL cholesterol .p < 0.0001).The LDL-C levels decreased from visit to visit in the combined nutraceutical group, and, on the contrary, increased in the placebo group. The mean change at week 8 was −32.5 ± 30.2 mg/dL (−19.8%) in the combined nutraceutical group and 2.5 ± 19.4 mg/dL (2.3%) in the placebo group. The ANCOVA model results for the estimated change from baseline at week 8 in LDL-C levels, adjusting for the baseline value of LDL-C, provided Least Squares Means equal to −34.5 mg/dL  for the combined nutraceutical group and 4.6 mg/dL  for the placebo group. The estimated between-group difference of −39.2 mg/dL  indicates a statistically significant difference between treatments in favor of the combined nutraceutical  for the combined nutraceutical group and 8.2 mg/dL  for the placebo group. The estimated between-group difference of −41.2 mg/dL  and a p < 0.0001).The Least Squares Means of non-HDL cholesterol change from baseline at week 8, estimated adjusting for baseline value, were equal to −34.2 mg/dL  in the combined nutraceutical group and 7.5 mg/dL  in the placebo group. The between-group difference of −41.7 mg/dL  was significantly in favor of treatment with the combined nutraceutical (p < 0.0001).The Least Squares Means of Apo B change at week 8, adjusting for baseline value, were −15.2 mg/dL  for the combined nutraceutical group and 2.0 mg/dL  for placebo. The between-group difference of −17.3 mg/dL  indicates a statistically significant difference between treatments in favor of the combined nutraceutical  for the combined nutraceutical group and 0.1  for placebo. The estimated between-group difference was −0.9 , and a p < 0.0001).The Least Squares Means of the LDL-C/HDL-C ratio change from baseline at week 8, adjusting for baseline value, were −0.8  for the combined nutraceutical group and 0.02  for the placebo group. The between-group difference of −0.8  was statistically significant , while it remained unchanged in the placebo group . This effect was observed after 4 weeks of treatment and confirmed after 8 weeks, excluding short-term adaptation phenomena. This is compatible with the mechanism of action of the nutraceutical components of the tested product. The LDL-C reduction that was achieved is near to that 39.8 mg/dL, which is estimated to be associated in long-term trials with a corresponding 22% reduction in cardiovascular mortality and morbidity [In our double-blind, placebo-controlled, randomized clinical trial, we observed that the LEVELIP DUOorbidity . On the orbidity .In this context, the tested combined nutraceutical was shown to be effective and well-tolerated. In 2017, the ILEP  classifi® is be related to the contents of phytosterols and red yeast rice. However, the minor components of the products could have also minimally contributed to the final effect. In particular, EFSA approves the health claim of niacin supporting energy metabolism and macronutrient metabolism [We can argue that the greater part of the observed effect of LEVELIP DUOtabolism . Policostabolism .Our study has some relevant limitations. The first one is the relatively low number of subjects investigated per treatment group, while, however, the study was sufficiently powered to detect differences between treatment groups. Of course, we could have used a cross-over design, but we feared losing the volunteers’ compliance to the treatment if the study duration was excessive. The second one is the lack of the measurement of markers of cholesterol absorption and synthesis, as cholesterol hyperabsorbers could have manifested a more significant LDL-C reduction than standard cholesterol absorbers . Finally® was well-tolerated while significantly reducing the plasma levels of LDL-C, TC, non-HDL-C, ApoB, TC/HDL-C and LDL/HDL-C ratios in mildly hypercholesterolemic patients. Further long-term studies are needed to confirm the maintenance of this impressive effect over time.LEVELIP DUO


Background: to date, little attention has been given to gender differences in the health of migrants relative to native-born. In this study, we examine the health profile of the largest immigrant groups in metropolitan France, considering several health indicators and with a special interest in the gendered patterns. Methods: The data originate from the 2017 Health Barometer survey representative of metropolitan France. A subsample of 19,857 individuals aged 18–70 years was analysed using modified Poisson regression, and risk ratio estimates (RR) were provided for the different migrant groups regarding alcohol use, current smoking, obesity and less-than-good self-reported health, adjusting for age and educational level. Results: None of the groups of male migrants differs from the native-born in terms of self-reported health, and they have healthier behaviours for alcohol (men from sub-Saharan Africa: 0.42 (0.29–0.61)) and from the Maghreb: 0.30 (0.1–0.54)) and smoking (men from sub-Saharan Africa: 0.64 (0.4–0.84)), with less frequent obesity (men from the Maghreb: 0.61 (0.3–0.95)). The latter, however, more frequently report current smoking (1.21 (1.0–1.46)). For women, less-than-good health is more frequently reported by the groups from sub-Saharan Africa (1.42 (1.1–1.75)) and from the Maghreb (1.55 (1.3–1.84)). Healthier behaviours were found for alcohol (women from overseas départements: 0.38 (0.1–0.85)) and from the Maghreb: (0.18 (0.0–0.57)) and current smoking (women from southern Europe: 0.68 (0.4–0.97), from sub-Saharan Africa: 0.23 (0.1–0.38) and from the Maghreb: 0.42 (0.2–0.61)). Conversely, some were more frequently obese (women from overseas départements: 1.79 (1.2–2.56) and from sub-Saharan Africa: 1.67 (1.2–2.23)). In the latter two groups from Africa, there is a larger relative male excess for tobacco than in the native-born  and 3.1 (2.0–4.65) vs 1.13 (1.0–1.20)) and there is a female excess for obesity (0.51 (0.2–0.89) and 0.41 (0.2–0.67)) in contrast with the native-born (1.07 (0.9–1.16)). The female disadvantage in terms of less-than-good self-reported health is more pronounced among migrants from the Maghreb than among the natives (0.56(0.4–0.46) vs. 0.86 (0.8–0.91)). Conclusion: Considering a set of four health indicators, we provide evidence for distinctive gender patterns among immigrants in France. Male immigrants have a healthy behavioural profile in comparison with the natives and no health disadvantage. Female immigrants have a more mixed profile, with a health disadvantage for the non-Western groups from Africa. The contribution to this discordance of socioeconomic factors and gender relations needs to be investigated. The “healthy migrant effect” and “unhealthy assimilation” hypotheses are dominant paradigms in the field of migrant health, reflecting the progressive deterioration over time of the initially superior health of migrants. Those paradigms have not been analysed with gender lens , which mHealth differences between men and women reflect in part the inequalities related to the gender roles, likely to be wider in some of the societies of origin of the immigrants. To start with, women in developing countries are more socially disadvantaged relative to men than women in developed countries. They indeed have lower employment rates, lower salaries and have to take charge of the bulk of childcare and domestic tasks. Although gender roles are likely to be renegotiated after migration, male and female migrants have very different employment trajectories, as the latter are directed to unskilled and caretaking services, with precarious job contracts and long working hours, in addition to a heavy load of domestic duties.The more proximal health determinants such as the health behaviours are influenced by social norms in the country of origin and assumed to converge with those of the destination country. There are also in this respect distinctive gender patterns. For instance, female immigrants from certain cultures may retain low alcohol and tobacco intake and distinctive reproductive patterns which may protect them from the major cancers, but those favourable features may be accompanied by unfavourable changes in terms of nutritional and cardiovascular risk factors ,3. On thYet, insufficient attention has been given in the international literature to gender differences in health behaviours and differential behavioural changes in immigrant populations in relation with the “unhealthy assimilation hypothesis”. Second, as the differences between migrants and native-born vary across health indicators, and as, above that, there are also distinctive gender patterns for different indicators, some authors have concluded that “presenting results on a single factor in isolation could lead to a misinterpretation of associations” . GeneralThere is a wealth of studies on migrants’ health in Europe but few provide comparisons with the native-born, and there is a large variability in design and methodology. In Spain, immigrants displayed better lifestyle-related parameters, with lower consumption of alcohol and tobacco than the autochtonous population, but consumption increased with duration of stay ,10. In FIn certain studies, gender was treated as a confounder . In ohttps://www.insee.fr/fr/statistiques/1410693). Our aim is to contribute to a better understanding of those insufficiently explored dimensions of gender patterns and health profiles of male and female immigrants, using data from metropolitan France.France offers excellent potential for exploring smoking disparities by geographical origin, given the diversity and importance of the groups present in the country. In 2014, the share of the immigrant population in France approached 9%  How do male and female migrants fare in terms of self-reported health in comparison with the native-born? , and; (2) What are the specific behavioural profiles of male and female migrants and how do they relate to their health profiles?We examine alcohol and tobacco use, corpulence and self-reported health in the largest immigrant groups originating from North Africa, sub-Saharan Africa, Southern Europe and French overseas departments. Our analytical approach involves analysis of the prevalence levels of the different conditions in immigrants relative to the native-born, separating men and women and adjusting on the main sociodemographic factors. In addition, we estimate male-to-female prevalence ratios in the different groups for the various health indicators. Our interpretation builds on this comprehensive set of statistics to describe the specific health profiles of the immigrant groups and their specific gender patterns relative to those of the native-born.The 2017 “Health Barometer” is a nationwide French survey that used a two-stage random  sample and a dual sampling frame (landline/mobile line) to measure health perceptions and behaviours of the general population . This inDaily tobacco smoking was defined as a current smoking of tobacco (whatever the type of product), excluding the electronic cigarette; regular alcohol use was defined as the report of at least 3 days of alcohol use per week in the last 12 months. Obesity was defined as a body mass index (BMI) over 30 based on reported weight and height; less than-good self-reported health as the report of a correct/poor/very poor health.départements; born in Southern Europe ; Maghrebins; born in sub-Saharan Africa  and natives from those colonies born without the French nationality, who are referred to hereinafter as the Maghrebins. The latter term (Maghrebins) is derived from an Arabic term for the North African region of origin, to refer to immigrants and their descendants who have neither European backgrounds nor Jewish origins . The anan Africa .As education is a major determinant of health behaviours , we consMultivariate dichotomous modified Poisson regressions  modellinImmigrants from Southern Europe belong to the oldest waves and stand out as being the older group (median ages of respectively 52 and 53 years), with the longest median duration of stay of all immigrant groups (46 years for both genders), and the smallest median age at migration (12 years for men and 15 years for women). The latter statistic indicates that a large proportion arrived as children either accompanying their parents or for family reunification. This group as a whole is also the least educated, but the gap may be partly explained by a cohort effect in a context of rising educational levels over time in all countries.départements (27% with low education vs. 24%).The two groups of immigrants from Overseas “Départements” and from the Maghreb are younger than the native-born (median ages in the early forties) and stand close to each other with respect to their median duration of stay and to their age at arrival, ranging around 20 years. Both have larger proportions of lower educated than the natives, with however a smaller gap for women from overseas As immigrants from sub-Saharan Africa belong to the most recent migratory wave represented in the study, they are the youngest group (median ages of respectively 41 years and 39 years for men and women), and their median duration of stay is relatively short (respectively 15 and 14 years). Their median age at migration is the highest of all groups (24 years for men and 21 years for women), reflecting the importance of labour migration. Overall, immigrants from sub-Saharan Africa are much less educated than the native-born .For each of the four health indicators, we conducted two series of stratified multivariate analyses in order to investigate: (1) the modifying effect of gender on migration-related disparities, and; (2) the modifying effect of migration background on gender disparities.Migration-related disparities for men and for women: this analysis examines the extent to which male and female immigrants are different in the way they compare to their native-born counterparts ) and, at the opposite, a much higher obesity prevalence than the native-born (1.79 (1.25–2.56)). In the group of immigrants from overseas In the group of immigrants from Southern Europe, males were similar in all respects to the reference population, unlike females, whose current smoking was significantly less frequent than that of the native-born (0.68 (0.47–0.97)).In the group of immigrants from sub-Saharan Africa, males had healthier behaviours than the native-born with respect to alcohol (0.42 (0.29–0.61)) and tobacco consumption (0.64 (0.49–0.84)). Females had an even greater advantage than males for tobacco (0.23 (0.14–0.38)), along with significant disadvantages in terms of obesity (1.67 (1.25–2.23)), and less-than-good self-reported health (1.42 (1.15–1.75)). In the group of immigrants from the Maghreb, men and women both had much lower prevalence of regular alcohol use (respectively 0.30 (0.16–0.54) and 0.18 (0.06–0.57)), while they had opposite patterns for tobacco, as current smoking was slightly more prevalent in men (1.21 (1.01–1.46)), and much less in females (0.42 (0.29–0.61)). Differences were also observed for obesity, as men had a specific advantage in this respect (0.61 (0.39–0.95)) and for less-than-good self-reported health, with a significant disadvantage for women (1.55 (1.30–1.84)).Gender disparities in immigrant groups and in natives: this analysis examines the male-to-female prevalence ratios in the different groups and compares the gender contrast for the different indicators to what is observed among the natives ) and a higher level of current smoking (1.13 (1.07–1.20)). Although their behaviours were less healthy, men were less likely than females to rate their health as less-than-good (0.86 (0.81–0.91)). p = 0.064). The gender relative difference for current smoking among immigrants from overseas départements (1.68 (1.04–2.71)) and among those from Southern Europe (1.60 (1.06–2.42)) was not significantly different from that found for the natives, while the gap was significantly larger for the groups from Africa (sub-Saharans 2.87 (1.61–5.09) and Maghrebins 3.10 (2.06–4.65)). The latter two groups were also the only groups for which there was a significant gender contrast for obesity, in favour of males (0.41 (0.25–0.67) for immigrants from sub-Saharan Africa and 0.51 (0.29–0.89) for immigrants from the Maghreb). Finally, immigrants from the Maghreb tended also to have lower gender-ratios than the natives for the less-than-good health (0.56 (0.41-0.76) vs. 0.86 (0.81–0.91) respectively).The gender distortion for less-than-good self-reported health was also found among immigrants from sub-Saharan Africa (0.65 (0.47–0.90)), and, to a much greater extent than among the natives, in the group from the Maghreb (0.56 (0.41–0.76)). For regular alcohol use, all immigrants except those coming from sub-Saharan Africa showed higher male-to-female risk ratios than the native born . On the opposite, the immigrants from sub-Saharan Africa showed a more gender-balanced ratio with RR = 1.64 (0.89–3.03) that was almost significantly lower than the ratio observed in the natives .Theoretically, the evidence can be interpreted within the framework of the so-called “healthy immigrant effect” and “unhealthy assimilation” hypotheses, and we propose to integrate the gender perspective to more fully interpret the findings. In a review on health-related lifestyles among immigrants in Europe, Spadea et al.  concludedépartements) and less tobacco  than the native-born. However, those favourable behaviours were partly offset by a higher prevalence of obesity (for those from French overseas départements and those from sub-Saharan Africa). The major difference between the two genders was that the two groups of non-Western female immigrants, i.e., those from sub-Saharan Africa and from the Maghreb, were the only groups with a significantly higher prevalence of less-than-good self-reported health than the native-born. This is all the more striking for females from the Maghreb, who would be expected to reap the health benefits of their very moderate tobacco and alcohol consumption.Non-Western male immigrants reported healthier behaviours than the native-born: for alcohol and tobacco in those from sub-Saharan Africa, and for alcohol and obesity for the Maghrebins, whose advantage was however mitigated by a significantly elevated tobacco consumption. Some female immigrants also tended to consume less alcohol .Our finding of both a higher smoking prevalence among Maghrebin men and a lower prevalence among sub-Saharan men in comparison with the native-born, as well as much lower levels for the females from the two groups accord with reports from earlier studies based on French national health surveys from the late eighties , the eardépartements , which represent the remainder of the past colonial empire, is predominantly Afro-Caribbean and Creole and on the whole socioeconomically disadvantaged.In a recent review of acculturation, obesity and health behaviours among immigrants to high-income countries , there wdépartements, although elevated, does not reach significance. For sub-Saharan females, the health disadvantage may be related to their higher prevalence of obesity, possibly associated with a range of chronic diseases (particularly diabetes) and physical or physiological limitations. As for the situation of Maghrebin females, it is paradoxical, as they have a favourable profile of health behaviours, notably for alcohol and tobacco consumption, and no disadvantage for obesity.In our study, the only assessment of health properly speaking was the subjective indicator of self-reported health. As was observed for obesity, we find a gendered pattern of disadvantage, with female immigrants from both sub-Saharan Africa and the Maghreb, much more likely to report less-than-good self-reported health than the native-born. The estimate for females from overseas The absence of evidence on predictors of bad health raises question on the nature of the conditions or diseases affecting this group of women from the Maghreb. In the literature, some studies echo this finding of gender-based differential health of immigrants. A specific disadvantage of female immigrants was observed in the adult population aged 25–64 living in Catalonia, Spain, as female immigrant groups showed excess risk of poor self-perceived health, whereas male immigrant groups had better health than natives in the same social class . Severaldépartements and those from sub-Saharan Africa, who are both characterized by a higher prevalence of obesity.Few empirical studies on health and health behaviours of immigrants have focused on gender-specific patterns in comparison with the native-born. Our study concerns groups of established migrants in France of whom the most recently arrived (from sub-Saharan Africa) have a median duration of stay around 15 years. We find a large amount of variation across regions of origin for both male and female migrants, as well as across genders. In terms of self-reported health, no male or female migrant group benefit from an advantage, whereas the two female groups from Africa display a significant disadvantage. In terms of behaviours, male migrants have similar or healthier behaviours than the native-born, with the exception of those from the Maghreb who are more likely to be regular smokers. Female migrants have similar or healthier behaviours than the natives, with the exception of those from overseas In summary, our findings do not provide evidence for either gender in support of the “healthy migrant hypothesis”. Conversely, the health situation of the two non-Western female groups (from sub-Saharan Africa and the Maghreb) is compatible with the “unhealthy assimilation” paradigm. The health disadvantage of females from sub-Saharan Africa may be related to their greater prevalence of obesity and possibly cardio-vascular risk factors. However, no explanation in terms of health behaviours emerges for females from the Maghreb. For this specific group, more traditional gender roles and the unequal division of productive and domestic work needs to be investigated.


Ankle syndesmosis injury is a common condition, and the injury mechanism can be sorted into pure syndesmosis injury, Weber-B, and Weber-C type fractures. This study aims to evaluate the treatment outcomes and stability of suture-button fixation for syndesmosis injury with different injury mechanisms. We hypothesized that injury mechanisms would alter the stability of suture-button fixation.We retrospectively reviewed 63 patients with ankle syndesmosis injury who underwent surgery with TightRope  from April 2014 to February 2019. The stability of suture-button fixation with TightRope was evaluated by comparing the preoperative, postoperative, and final follow-up measurements of tibiofibular clear space (TFCS), tibiofibular overlap (TFO), and medial clear space (MCS). A subgroup analysis for each demographic group and injury type including pure syndesmosis injury, Weber-B, and Weber-C type fractures were performed.p < 0.01 and TFO 6.86 to 6.29 mm, p = 0.04). Though widened, the final follow-up values of tibiofibular clear space and tibiofibular overlap were in the acceptable range. Postoperatively and at the final follow-up, medial clear space was found to be significantly larger in the Weber-C group than in the pure syndesmosis and Weber-B groups (p < 0.05).Syndesmosis was effectively reduced using TightRope. After the index surgery, the tibiofibular clear space was reduced from 7.73 to 4.04 mm, the tibiofibular overlap was increased from 3.05 to 6.44 mm, and the medial clear space was reduced from 8.12 to 3.54 mm. However, syndesmosis widening was noted at the final follow-up, especially in Weber-C type fractures (TFCS 3.82 to 4.45 mm, Suture-button fixation can offer anatomic reduction and dynamic fixation in syndesmosis injuries. However, when using this modality for Weber-C type fractures, more attention should be focused on the accuracy of reduction, especially of medial clear space, and rediastasis should be carefully monitored.This trial was retrospectively approved by TMU-JIRB. Registration number N202004122, and the date of approval was May 06, 2020.III Ankle syndesmosis injury is a common condition, which can be a consequence of a simple fall, sports injury, motor vehicle accident, or fall from a height. The injury can occur as an isolated ligamentous tear or along with fractures. Studies have estimated that 10% of all ankle fractures and 20% of operatively treated ankle fractures occur along with syndesmosis injury . AccordiThe present study evaluated the treatment radiologic outcomes and stability of fixation with suture-button fixation in syndesmosis injury with different injury mechanisms. We hypothesized that the stability of suture-button fixation would vary based on different injury mechanisms.In the present study, we retrospectively examined 63 patients who underwent suture-button fixation for ankle syndesmosis with TightRope  from January 2014 to February 2019. This study had 3 inclusion criteria adopted from previous studies: (1) presence of preoperative diastasis of tibiofibular clear space (TFCS) > 6 mm as measured in the standard anteroposterior (AP) view or mortise view, (2) preoperative MRI image with increased signal in T2-weighted imaging of interosseous space presenting disruption of the anteroinferior tibiofibular ligament (AITFL) or posteroinferior tibiofibular ligament (PITFL), and (3) occurrence of intraoperative movement > 3 mm after bony fixation by pulling of the fibula laterally with a towel clip [Surgery was performed under general or spinal anesthesia in the supine position with a bump under the hip. If any fracture is present, open reduction and internal fixation with either plate or screws was done, followed by intraoperative evaluation of the syndesmosis by lateral pull of fibula. After syndesmosis instability was confirmed, syndesmosis fixation was performed through the following steps. First, open reduction of the syndesmosis was done under direct visualization and temporarily fixed with a k-wire. Thereafter, we used a guide pin to locate the optimal insertion site and trajectory. The site of insertion was 2–4 cm above the ankle joint aimed parallel to the joint and 20 to 30° anteriorly in the coronal plane from the fibula to tibia. After the guide pin was passed through the ideal tract, reaming was performed to open the canal for suture-button passage. The suture-button was passed through the guide needle with pull-through sutures, and then, the oblong button was flipped to rest on the medial cortex of the distal tibia. The position and reduction were determined under fluoroscopy, and then, the suture was tightened until the lateral button rested on the distal fibular cortex or lateral malleolar plate if present Fig. .Fig. 1XAfter surgery, all patients were immobilized with a below-knee splint and maintained a non-weight-bearing status for 2 weeks and then protected weight bearing for another 4 weeks. Full weight bearing was allowed 6 weeks after surgery. A monthly outpatient follow-up was performed for at least 6 months. Implants were removed only if local discomfort was claimed or requested by the patient.Both AP, lateral, and mortise views of the ankle were taken at each time points, namely pre-operative, post-operative, and final follow-up. The pre-operative and post-operative X-rays were taken in supine position, and the final follow-up X-rays were taken under weight-bearing condition. The imaging techniques were standardized as follows.For non-weight bearing AP views, the patient lay supine on examination table, with a pillow under head and leg fully extended. The foot was placed vertically on the image receptor, in neutral extended position. Slight foot pronation may be required for true AP position. For non-weight bearing mortise views, the patient positioned same as AP view, with the ankle internally rotated 15 to 20° until the intermalleolar line was parallel to the image receptor. For AP and mortise views, the central ray was perpendicular to the receptor and directed at a point midway between the malleoli , 23. ForFor weight-bearing AP and lateral views, have the patient stand erect with weight evenly distributed on both feet. The feet should be directed straight ahead and parallel to each other. The placement of image receptor and direction of the central ray was same as non-weight-bearing views. For weight-bearing mortise views, have the patient stand erect with weight evenly distributed on both feet. Place the image receptor behind the feet, internally rotate the injured leg by 15 to 20°, until the intermalleolar line was parallel to the image receptor , 23.For all above images, the source to image distance was set to 102 cm (40 in.) , 23.Radiographic measurements were done at both 3 time points mentioned above. The tibiofibular clear space (TFCS) was measured as the distance between the medial border of the fibula and the incisura fibularis on a line parallel and 1 cm above the tibia plafond on AP view. The tibiofibular overlap (TFO) was measured as the maximum amount of overlap on mortise view , 25. Thet test was used to compare preoperative, postoperative, and final follow-up measurements. Then, the one-way analysis of variance test and Welch test were used for comparing final follow-up measurements between the groups. All analyses were performed using SPSS, version 19.0 .Patients were grouped based on the injury pattern, which included pure syndesmotic injury, Weber-B type fracture, and Weber-C type fracture . The paiA total of 63 patients were included, of whom 37 (59%) were men and 26 41%) were women, with a mean age 41.4 years (range 18–71 years). Ten (16%) patients had pure syndesmotic injury, 25 (40%) had Weber-B type fracture, and 28 (44%) had Weber-C type fracture  patients in the pure syndesmosis group, 3 (11.1%) patients in the Weber-B group, and 4 (13.8%) patients in the Weber-C group. A TFO change greater than 2 mm was observed in no (0%) patients in the pure syndesmosis group, 1 (3.7%) patient in the Weber-B group, and 8 (27.6%) patients in the Weber-C group. Finally, an MCS change greater than 2 mm was observed in no (0%) patients at the final follow-up.p = 0.003) and Weber-B groups (p = 0.029). Regarding final follow-up measurements, a significantly greater MCS was also observed in the Weber-C group than in the pure syndesmosis (p < 0.001) and Weber-B groups (p = 0.017). However, no significant difference was found between the groups for TFCS and TFO at both time points  had MCS greater than 4 mm after index surgery, 7 patients (25%) had TFO lesser than 6 mm, and 6 patients (21%) had TFCS greater than 6 mm. When postoperative measurements were compared between the groups, MCS was found to be significantly greater in the Weber-C group than in the other groups. The same results were also noted for final follow-up measurements, with the mean MCS value being slightly greater in the Weber-C group than in other groups.To summarize the findings, the preoperative and immediate postoperative MCS were wider in Weber-C type fractures than in other types of injuries, and malreduction in MCS was more common in Weber-C type fractures when compared with different injury mechanisms. Alternatively, rediastasis was more likely to occur in Weber-C type fractures after weight bearing by the affected limb. These findings may be attributed to higher force applied to the affected ankle at the time of injury, greater initial displacement, and more commonly to fracture dislocation of the ankle. To date, various cohort studies have supported the use of suture-button fixation because it provides sufficient longevity and comparable outcomes as syndesmotic screw fixation , 28–30. We also found widening of TFCS and MCS in nearly all groups after suture-button syndesmosis fixation. Andersen et al. compared difference of tibiofibular distance with the injured and uninjured leg, which found that the distance of the injured leg increased after 1 year and 2 years follow-up . TeramotThe implant removal rate (22%) was higher in our study than in previous studies. Among the 14 patients who underwent implant removal, 7 underwent implant removal along with the removal of the lateral malleolar plate, whereas the remaining 7 underwent removal of the suture-button implants only. Furthermore, only 2 patients experienced severe soft tissue irritation and abscess formation. Knot irritation (19%) and surgical site infection (8%) were believed to be the most common complications related to this technique –18. NaqvThis study has several limitations. This retrospective study used only plain films for interpreting the button placement and syndesmosis distance and lacked a subjective functional score for outcome evaluation . No veriSuture-button fixation is an effective treatment modality for ankle syndesmosis injury combined with and without fracture. This technique leads to dynamic fixation without requiring implant removal routinely. However, when using this modality for Weber-C type fractures, more attention should be focused on the accuracy of reduction, especially of MCS, and rediastasis should be carefully monitored.